PubMed · 15096350
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David B Edwards. 2004-04-20. Computer physician order entry.. https://doi.org/10.7326/0003-4819-140-8-200404200-00029
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We conducted a drastic change in our hospital information system to support patient participatory health care provided in the New Hiroshima University Hospital (HUH). The new information system in HUH (HU-MIND II-Hiroshima University Hospital Medical Intelligence and Notice Delivery system II) is designed as "clinical management system" (CMS). The core of this CMS is the electronic health record (EHR), which aims to assure both the patients' right to know, and the attendants' accountability. It is evident that the team practice including patients requires close communication. Data in the EHR are written not only by physicians, but also by all coworkers, which will enable them to realize the team communication and the ordering in a reliable way and to leave the evidence of conducted practices. Moreover, the bedside information systems were set-up at all 700 beds. Patients can access their anamnesis and future clinical care procedures themselves. Based on the demand outlined above, the new regulations of HUH are composed of 21 requirements, conditions of information collection, accumulation and use. Our focus was how to make patients' right compatible with attendants' accountability. As the data owners, patients have the facility to access their own data at their bedsides. They can view their own health condition and treatment program and can control the data flow.
Librarians at the UMDNJ Cooper Library have been filling orders for patient education materials through Cooper University Hospital's Clinical Information System (CIS) since December 2000. This service was instituted in response to a JCAHO survey, which revealed that although patient education was being provided, it was not being routinely documented. Patient education orders fall into two categories: customized disease/procedure information and smoking cessation information. Nurses note the condition(s) and/or procedure(s) regarding which information is needed and indicate the education level of the material desired (basic, intermediate or advanced). Requests are received via a dedicated printer in the reference office. Librarians rely heavily upon a wide variety of Web-based consumer health resources, including proprietary resources such as MD Consult and Micromedex CareNotes. Patient Transport staff delivers two copies of all materials to nursing stations on patient care floors. One copy is for the patient to keep, while the other is attached to the patient's chart. To complete and document that patient education was provided, librarians record the order as filled in the CIS system.